Provider Demographics
NPI:1639948730
Name:ANDERSON, ADAM W (PSYCH ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:W
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PSYCH ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4909 W LEIGHSON AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-7860
Mailing Address - Country:US
Mailing Address - Phone:559-306-2533
Mailing Address - Fax:
Practice Address - Street 1:6250 N MILLBROOK AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5620
Practice Address - Country:US
Practice Address - Phone:559-431-4787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-29
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
CAPSB94026682103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist